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Intelligent Clinical Documentation: Harnessing Generative AI for Patient-Centric Clinical Note Generation

Anjanava Biswas, Wrick Talukdar, Aws Ai, Ieee Ml, Cis (2024)

Paper Information
arXiv ID
Venue
International Journal of Innovative Science and Research Technology
Domain
Healthcare, Artificial Intelligence, Medical Informatics
Reproducibility
7/10

Abstract

Comprehensive clinical documentation is crucial for effective healthcare delivery, yet it poses a significant burden on healthcare professionals, leading to burnout, increased medical errors, and compromised patient safety.This paper explores the potential of generative AI (Artificial Intelligence) to streamline the clinical documentation process, specifically focusing on generating SOAP (Subjective, Objective, Assessment, Plan) and BIRP (Behavior, Intervention, Response, Plan) notes.We present a case study demonstrating the application of natural language processing (NLP) and automatic speech recognition (ASR) technologies to transcribe patient-clinician interactions, coupled with advanced prompting techniques to generate draft clinical notes using large language models (LLMs).The study highlights the benefits of this approach, including time savings, improved documentation quality, and enhanced patient-centered care.Additionally, we discuss ethical considerations, such as maintaining patient confidentiality and addressing model biases, underscoring the need for responsible deployment of generative AI in healthcare settings.The findings suggest that generative AI has the potential to revolutionize clinical documentation practices, alleviating administrative burdens and enabling healthcare professionals to focus more on direct patient care.I.

Summary

This paper explores the application of generative AI in clinical documentation, focusing on the generation of SOAP and BIRP notes. It highlights the burden of documentation on healthcare professionals and proposes a case study that employs natural language processing (NLP) and automatic speech recognition (ASR) to streamline the process. The methodology involves data collection from simulated patient-clinician interactions, transcription of dialogues, and the use of various large language models (LLMs) to generate structured clinical notes. The study addresses ethical considerations, compares AI performance, and emphasizes the need for iterative note improvement and human oversight. Challenges such as data quality, privacy concerns, and regulatory compliance are discussed along with future research directions.

Methods

This paper employs the following methods:

  • Natural Language Processing (NLP)
  • Automatic Speech Recognition (ASR)
  • Prompt Engineering
  • Large Language Models (LLMs)

Models Used

  • ChatGPT-4
  • GPT-3.5
  • Claude V3
  • Mixtral8x7b Instruct
  • Llama-3 70B Instruct

Datasets

The following datasets were used in this research:

  • None specified

Evaluation Metrics

  • ROUGE-1
  • Accuracy
  • Precision
  • Recall
  • F1-score

Results

  • Demonstrated time savings in documentation
  • Improved documentation quality
  • Enhanced patient-centered care

Limitations

The authors identified the following limitations:

  • Not specified

Technical Requirements

  • Number of GPUs: None specified
  • GPU Type: None specified

Keywords

Generative AI Clinical documentation SOAP notes BIRP notes Natural language processing Automatic speech recognition Large language models AI in healthcare

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External Resources